NIHSS Score Administration and Interpretation 5 — Questions and Answers
Question 1: Which of the following best describes the 'first response' rule in NIHSS scoring?
- The examiner may repeat each item up to three times and score the best attempt
- The examiner scores the patient's initial response to a stimulus without coaching (Correct answer)
- The examiner scores only the last response if the patient self-corrects
- The examiner averages all attempts and rounds to the nearest integer
Correct answer: The examiner scores the patient's initial response to a stimulus without coaching
The NIHSS first-response rule requires scoring the patient's initial, uncoached response to maintain standardization.
Question 2: A patient can only partially close one eye and the nasolabial fold is slightly flattened on the right. The facial palsy score should be:
- 0 — normal
- 1 — minor paralysis
- 2 — partial paralysis (Correct answer)
- 3 — complete paralysis
Correct answer: 2 — partial paralysis
Partial paralysis (score 2) describes total or near-total paralysis of the lower face and incomplete closure of the upper face.
Question 3: During visual field testing (Item 3), a patient correctly identifies fingers in all quadrants. Suddenly the patient extinguishes stimuli on the left during simultaneous bilateral stimulation. How should Item 3 be scored?
- 0 — no visual loss because quadrant testing was intact
- 1 — partial hemianopia (Correct answer)
- 2 — complete hemianopia
- 3 — bilateral blindness
Correct answer: 1 — partial hemianopia
Extinction on double simultaneous stimulation with intact monocular fields is scored as partial hemianopia (1) on Item 3.
Question 4: In the context of serial NIHSS assessments, what does a decrease in NIHSS score of 4 or more points typically indicate?
- Hemorrhagic transformation
- Clinically meaningful neurological improvement (Correct answer)
- Medication-induced sedation effect
- Measurement error requiring reassessment
Correct answer: Clinically meaningful neurological improvement
A ≥4-point decrease in NIHSS score is widely accepted as a threshold for clinically meaningful neurological improvement.
Question 5: A patient follows simple commands during LOC Commands testing (Item 1b) but only after the examiner repeats each question twice. The correct score is:
- 0 — correctly performed both tasks (Correct answer)
- 1 — performs one task correctly
- 1 — repeated commands require a score of 1
- 2 — performs neither task correctly
Correct answer: 0 — correctly performed both tasks
Item 1b is scored on whether the patient correctly performs the task, not on how many repetitions were needed, so correct performance on both tasks = 0.
Question 6: When assessing best gaze (Item 2), a patient with a known chronic gaze palsy from a prior stroke shows no new deviation. The examiner should:
- Score the item based on current examination findings regardless of history (Correct answer)
- Score 0 because the deficit is not acute
- Skip the item and mark it as UN
- Subtract the prior deficit score from the current score
Correct answer: Score the item based on current examination findings regardless of history
NIHSS protocol requires scoring based on current examination findings; prior deficits are not subtracted, but the examiner notes them in documentation.
Question 7: A patient's NIHSS sensory item (Item 8) is being tested with pinprick. She reports reduced sensation on her left side but rates it as only 'slightly less sharp.' The correct score is:
- 0 — normal, slight difference is within normal variation
- 1 — mild-to-moderate sensory loss (Correct answer)
- 2 — severe to total sensory loss
- UN — untestable due to subjective reporting
Correct answer: 1 — mild-to-moderate sensory loss
A mild-to-moderate subjective reduction in sensation that the patient can still perceive is scored as 1 on the NIHSS sensory item.
NIHSS Score Administration and Interpretation 5
Which of the following best describes the 'first response' rule in NIHSS scoring?